NUR 3104-002 Nsg Adults & Older Adults: Care & Management of Patients with Diabetes Lecture

Related complications of Diabetes

▪ Lower – Extremity Amputations

▪ Heart Disease

▪ Stroke

▪ Neuropathy

▪ Diabetic eye disease

▪ End-stage renal disease (ESRD)

Pancreas Produces and Secretes

Beta Cells:

• Insulin (lets glucose IN)

Alpha Cells

• Glucagon (releases stored glucose OUT)

Glucose and Insulin Metabolism

Insulin binds to receptors along the cell walls of muscle, adipose, and liver cells.

• Glucose transport proteins (GLUT 4) then attach to the cell wall and allow glucose to enter the cell, where it is either stored or used to make energy.

Insulin

Lowers Blood Glucose:

• Glucose Uptake: Transports glucose into the cell

• Glycogen Synthesis: Converts glucose to glycogen for storage in muscle and liver tissue

• Fat storage: Stores excess glucose as fat in adipose tissue

• Protein Synthesis: Stimulates protein synthesis in cells

Stimulus: Blood Glucose Levels Rise

1. Beta cells in the pancreas release insulin into the blood

2. Insulin transports glucose into the cell

3. The liver takes up glucose and stores it as glycogen (glycogenesis)

4. Blood glucose levels = decline

Insulin STOPS:

• Conversion of stored glycogen to glucose in the liver (Glycogenolysis)

• Formation of new glucose or glycogen from non-carbohydrate sources (fats and proteins) (Gluconeogenesis)

Glucagon:

Promotes activities that raise blood sugar

▪ Conversion of stored glycogen to glucose (Glycogenolysis)

▪ Formation of glucose from protein and fat sources (Gluconeogenesis)

Stimulus: Blood Levels Fall

1. Blood levels fall

2. Alpha cells in the pancreas release glucagon

3. Glucagon promotes the conversion of glycogen to glucose

4. The liver breaks down glycogen and releases glucose (glycogenolysis)

5. Blood Glucose Rises

Hormones Affecting (Carbohydrate) Metabolism:

▪ Glucagon

▪ Cortisol

- Steroid medications (ex. Prednisone)

▪ Growth Hormone

▪ Epinephrine

ALL RAISE BLOOD GLUCOSE

Diabetes Etiology and Pathophysiology

Combination of causative factors

▪ Genetic

▪ Autoimmune

▪ Environmental

▪ Absent/insufficient insulin and/or poor utilization of insulin

Type 1 Diabetes (T1D): Etiology and Pathophysiology

Autoimmune disorder

▪ Body develops antibodies against insulin and/or pancreatic β cells ( β-cell destruction)

▪ Results in not enough insulin to survive

Genetic link

Idiopathic diabetes

Latent autoimmune diabetes in adults (LADA)

Type 1 Diabetes (T1D): Onset and Progression

Onset at any age, but usually young (age < 30 yrs)

▪ Autoantibodies are present for months to years before symptoms occur

▪ Manifestations develop when the pancreas can no longer produce insulin, then there is a rapid onset of Ketoacidosis

▪ Patient may have temporary remission after initial treatment = “honeymoon period”

Ketoacidosis:

Occurs when body doesn’t have enough insulin and body starts breaking down fat for energy.

• This process produces ketones, which are acidic

Classification of Diabetes: Type 1 Diabetes (T1D) Prevalence

Accounts for about 5% to 10% of all people with diabetes

Type 1 Diabetes: Clinical Manifestations

Classic symptoms “Three P’s”

▪ Polyuria (frequent urination)

▪ Polydipsia (excessive thirst)

▪ Polyphagia (excessive hunger)

Weight loss

▪ Additional symptoms: Nausea / vomiting / abdominal pain

Weakness/Fatigue

Dry mouth

Slow healing cuts/wounds

Classification of Diabetes: Type 2 Diabetes (T2DM)

Insulin resistance: Progressive insulin secretory defect

Caused by:

• Genetic link

• Decreased insulin production

• Inappropriate hepatic glucose production

• Altered production of hormones and cytokines by adipose tissue (adipokines)

• Brain, kidney, and gut metabolic factors

Type 2 Diabetes (T2DM): Onset

Gradual onset

▪ Hyperglycemia may go many years without being detected

▪ Often discovered with routine laboratory testing

At time of diagnosis:

— About 50% to 80% of β cells are no longer secreting insulin

— The average person has had diabetes for 6.5 years

Type 2 Diabetes T2DM: Risk Factors

Overweight/obesity,

Advanced age

Family history: hypertension (≥140/90), hyperlipidemia, gestational diabetes, metabolic syndrome

Type 2 Diabetes T2DM: Clinical Manifestations

Nonspecific symptoms

▪ Classic symptoms of type 1 may manifest (three p’s)

▪ Fatigue

▪ Recurrent yeast infections in both men & women

▪ Prolonged wound healing

▪ Visual changes

Type 2 Diabetes T2DM: Prevalence

▪ Most prevalent type (90% to 95%)

▪ Increasing prevalence in children

▪ Greater prevalence in ethnic groups

Classification of Diabetes: Gestational diabetes mellitus (GDM)

Diagnosed in the 2^nd or 3^rd trimester of pregnancy

Prediabetes:

Increased risk for developing type 2 diabetes ONLY

▪ Intermediate stage between normal glucose homeostasis and diabetes where the blood glucose levels are elevated, but not high enough to meet the diagnostic criteria for diabetes

Classification of Diabetes: General Types:

Genetic defects in β-cell function, insulin action

Diseases of the exocrine pancreas (CF and pancreatitis)

Drug-or chemical-induced

Diabetes Diagnostic Studies: Hemoglobin

HemoglobinA1C (HbA1C)

▪ Reflects glucose levels over the past 2 to 3 months

▪ Used to diagnose, monitor response to therapy, and screen patients

NTK!!: Lab Value Hemoglobin A1C Diabetes

▪ > 6.5% = diabetes

▪ For most goal A1c: < 6.5% to 7%

NTK!!: Lab Value Hemoglobin A1C Pre-Diabetes

▪ 5.7% – 6.4% = prediabetes

NTK!!: Lab Value Fasting Plasma Glucose (FPG) Prediabetes

FPG 100-125mg/dl = Prediabetes

NTK!!: Lab Value Fasting Plasma Glucose (FPG) Diabetes

FPG ≥ 126 mg/dL = Diabetes

NTK!!: Lab Value 2-hour Plasma Glucose Diabetes

2-hour PG ≥ 200 mg/dL = Diabetes

NTK!!: Lab Value 2-hour Plasma Glucose Pre-Diabetes

2-hour PG 140-199 mg/dL = Pre-Diabetes

NTK!!: Lab Value Random Plasma Glucose Draw Diabetes

RPG ≥ 200 mg/dL + symptoms = Diabetes

Diabetes Diagnostic Studies: Oral Glucose Tolerance Test (OGTT) Adult

Adult: 2-Hour Test

• 8oz with 75 grams of sugar

• Blood drawn before drinking and 2 hours after

Diabetes Diagnostic Studies: Oral Glucose Tolerance Test (OGTT) Child

Child: 2-Hour Test

• 1.75g of sugar per /kg

• Blood drawn before and two hours after

Diabetes Diagnostic Studies: Oral Glucose Tolerance Test (OGTT) Pregnancy

Pregnancy: 3 Hour Test

• 8oz with 100g of sugar

• Blood drawn before drinking and at 1, 2, and 3 hours after

Diabetes Diagnostic Studies: Fructosamine

▪ Reflects blood glucose in the previous 1-3 weeks

▪ Can use a formula to obtain A1c conversion

Diabetes Diagnostic Studies: Autoantibodies

Use autoantibodies to distinguish between T1D and other causes

Medications for DM Management: T1D

Insulin

•SQ or IV

(NOT orally, NOT in tube feedings)

Medications for DM Management: T2DM

• Oral hypoglycemic agents

• Insulin

Other injectables

Insulin Categorization

Categorized by Onset, Peak Action, and Duration:

○Rapid-acting

○Short-acting

○Intermediate-acting

○Long-acting

Basal Insulin

• Often referred to as “background” insulin

A healthy pancreas produces insulin every few minutes, 24 hours a day.

•Also increases insulin response to meals.

Long-Acting Insulin

• Degludec

• Detemir (Levemir)

• Glargine (Lantus)

— Given as Basal Insulin

■ Released steadily and continuously with no peak action for many people

■ Administered once or twice a day

DO NOT MIX WITH ANY OTHER INSULIN OR SOLUTION

Long-Acting Insulin Onset

3-6 Hours

(Degludec 1hr)

Long-Acting Insulin PEAK

9h continuous Peak for LONG acting insulin

Long-Acting Insulin Duration

24-Hour

Intermediate-acting Insulin

Neutral Protamine Hagedorn (NPH)

— can also be used for basal insulin

• Can mix with short & rapid-acting

• Cloudy; must be agitated to mix

Intermediate-acting Insulin (NPH) Onset

1-1.5 hours

Intermediate-acting Insulin (NPH) PEAK

4-12 Hours

Intermediate-acting Insulin (NPH) Duration

Up to 24 hours of duration (Intermediate acting insulin)

Rapid-Acting Insulin

• Lispro (Humalog)

• Aspart (Novolog & Fiasp),

• Glulisine (Apidra)

Injected within 15 minutes of mealtime

Rapid Acting Insulin (LAG) ONSET

About 15 minutes

Rapid Acting Insulin (LAG) PEAK

1-3 hours

Rapid Acting Insulin (LAG) Duration

3-5 hours

Short-Acing Insulin

• Regular (Humulin R, Novolin R)

Injected 30 to 45 minutes before meal

Short-Acing Insulin (Regular) Onset

Onset of action 30 to 60 minutes

Short-Acing Insulin (Regular) PEAK

0.5-2.5 hours

Short-Acing Insulin (Regular) Duration

8 hours

Sample Sliding Scale Insulin

Additional units of insulin that are dosed based on BG at the time of insulin administration.

Example: Measure BG at 7am -11am - 4pm - 9pm

Type of insulin administered: Regular (Short-Acting) or Rapid Acting

NOTE: Insulin Pumps

• Insulin pumps deliver only RAPID ACTING INSULIN

Storage of Insulin

○ Do not heat/freeze

○ In-use vials may be left at room temperature up to 4 weeks

○ Extra insulin should be refrigerated

○ Avoid exposure to direct sunlight, extreme heat or cold

○ Store prefilled syringes upright for 1 week if 2 insulin types; 30 days for one

Administration of Insulin (Pharmacokinetics)

Given by subcutaneous (SQ) injection

• Regular insulin may be given IV

• Cannot be taken orally

SubQ Administration of Insulin

Absorption is fastest from the abdomen,

• followed by the arm, thigh, and buttock

Inject at a 45- 90-degree angle

• Hold for 5 seconds

○ Abdomen is often the preferred site

Potential Complications of Insulin Therapy

○ Hypoglycemia !!!!

○ Allergic reaction

○ Lipodystrophy

Diabetic medications that cause WEIGHT GAIN

• Insulin

• Sulfonylureas

• Meglitinides

Acronym (ISM)

Diabetic medications that cause WEIGHT LOSS

• Metformin

• GLP-1 agonists

• SLGT2 Inhibitors

Acronym (MGS)

Diabetic Medications Administered (PO)

• Metformin

• Sulfonylureas

• Meglitinides

• DPP-4 Inhibitors

• SGLT2 Inhibitors

Diabetic Medications Administered (IM)

• Insulin

• GLP-1 Agonists

Diabetec Medication Uses: T1D

• INSULIN

Only INSULIN is used to treat Type 1 Diabetes

Diabetec Medication Uses: T2DM

• Insulin

• GLP-1 Agonists

• Metformin

• Sulfonylureas

• Meglitinides

• DPP-4 Inhibitors

• SGLT2 Inhibitors

Biguanides (Metformin) MOA

Metformin:

• Reduces glucose production by the liver

• Enhances insulin sensitivity

• Improves glucose transport

Biguanides (Metformin) Side Effects

Common side effects of Metformin include:

• May cause weight loss

• GI Disturbances

• Lactic acidosis (rare)

Biguanides (Metformin) Nursing Considerations

HOLD Metformin:

• If PT is undergoing surgery or a radiologic procedure w/ contrast medium

  • 1-2 days before and at least 48 hours after

• Monitor serum creatinine

Biguanides ( Metformin) Contraindication

DON’T administer Metformin if a PT has:

• Renal, liver, and/or cardiac disease

• Excessive alcohol intake

Dipeptidyl Peptidase–4 (DPP-4) Inhibitor (GLIPTIN) NTK

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin(Tradjenta

Dipeptidyl Peptidase–4 (DPP-4) Inhibitor (GLIPTIN) MOA

DPP-4 (Gliptin) Inhibitors:

• Block inactivation of incretin hormones

  • Increases Insulin release

  • Decrease Glucagon secretion

  • Decreases hepatic glucose production

Dipeptidyl Peptidase–4 (DPP-4) Inhibitor (GLIPTIN) Side Effects

Common side effects of DPP-4 (Gliptin)

• Headache

• Stuffy, runny nose

• Hypoglycemia

Dipeptidyl Peptidase–4 (DPP-4) Inhibitor (GLIPTIN) Nursing Considerations

• (GLIPTIN) Nursing Considerations

Instruct the patient about the signs and symptoms of hypoglycemia and other adverse effects to report

• Monitor kidney function

Glucagon-like Peptide-1 Receptor Agonists (GLP-1) NTK

End in “TIDE”

Liraglutide (Victoza, Saxenda) - daily

Semaglutide (Ozempic, Wegovy)

Glucagon-like Peptide-1 Receptor Agonists (GLP-1) MOA

GLP1s:

• Increase glucose-dependent insulin secretion

• Inhibit glucagon secretion

• Slow gastric emptying

• Increases satiety

Glucagon-like Peptide-1 Receptor Agonists (GLP-1) Side Effects

Common side effects of GLP1s:

• Weight loss

• Pancreatitis

• GI upset: diarrhea, nausea, vomiting

• Reaction at injection site

Glucagon-like Peptide-1 Receptor Agonists (GLP-1) Nursing Considerations

(GLP-1) Nursing Considerations:

Not recommended in patients with preexisting severe gastrointestinal disease,

- including severe gastroparesis

• Monitor for pancreatitis

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors MOA

End in “gliflozin”

• Blocks reabsorption of glucose by kidneys

• Increases glucose excretion

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors Side Effects

Common side effects of SGLTs

• Hypoglycemia (less severe, caused by Glycosuria)

• UTIs

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors Nursing Considerations

SGLT2 Inhibitors Nursing Considerations:

Monitor for genital or urinary tract infections

• Take once daily before the first meal in the morning

• Monitor Creatnine levels

Sulfonylureas 

End in “ide”

Increase Insulin production from the pancreas

Sulfonylureas Side Effects

Common side effects of Sulfonylureas

• **Hypoglycemia (severe)

• Weight gain

• Drug-drug interactions (NSAIDS, warfarin)

Sulfonylureas Nursing Considerations

Sulfonylureas Nursing Considerations

• Monitor for hypoglycemia

• Contraindicated with sulfa allergy

• Monitor serum creatinine

• Avoid alcohol use

• BEERS criteria (avoid in the elderly)

Thiazolidinediones

End in “litazone”

• Improve insulin sensitivity, transport, and utilization at target tissues

Thiazolidinediones Side Effects

Common side effects of Thiazolidinediones

• Hypoglycemia

• Anemia

• Weight gain, edema

• Decreased effectiveness of oral contraceptives

• Possible liver dysfunction

• Impaired platelet function

Thiazolidinediones Nursing Considerations

Thiazolidinediones Nursing Considerations

• Monitor liver function tests

• Instruct patient taking oral contraceptives about increased risk of pregnancy

Nutritional Therapy (MNT)

● Counseling

● Education

● Ongoing monitoring

● Interprofessional team

○ Registered dietitian with expertise in diabetes management

Nutritional Therapy Goals

● ADA healthy food choices

○ Maintain blood glucose levels to as close to normal as safely possible

○ Normal lipid profiles and blood pressure

○ Prevent or slow complications

○ Individual needs; personal, cultural preferences

○ Maintain pleasure of eating

Nutritional Therapy: ABCS of Diabetes

A = hemoglobin A1c

B = Blood Pressure

C = Cholesterol

Exercise:

● Start slowly after medical clearance

● Monitor blood glucose

● Glucose-lowering effect up to 48 hours after exercise

● Exercise 1 hour after a meal

● Snack to prevent hypoglycemia (~15g carb prior to exercise)

● Individuals with SMBG > 250 mg/dL (14 mmol/L) and who have ketones in their urine should not begin exercising until the urine test results are negative for ketones and the blood glucose level is closer to normal

Self-Monitoring of Blood Glucose (SMBG)

• Patient teaching

  • How to use, calibrate

• When to test

  • Before meals

  • Two hours after meals

  • When hypoglycemia is suspected

  • During illness

  • Before, during, and after exercise

Continuous Glucose Monitoring (CGM)

• Alternative blood sampling sites

• Displays glucose values with updating every 1 to 5 minutes

• Helps identify trends and track patterns

• Alerts to hypoglycemia or hyperglycemia

Bariatric Surgery

• Must have BMI >35 kg/m²

When lifestyle and drug therapy management is difficult

Pancreas Transplantation

● For type 1 diabetes with kidney transplant

● Eliminates need for exogenous insulin, SMBG, dietary restrictions

● Can also eliminate acute complications

● Lifelong immunosuppression

Nursing Assessment for Individuals Living with Diabetes: Subjective PMHX

Past health history

Including: Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes

Nursing Assessment for Individuals Living with Diabetes: Assess Medications

Insulin, OAs, corticosteroids, diuretics, phenytoin, beta-blockers